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Objective: The objective for this systematic review is to characterize clinical presentations of Bezold's abscesses to improve awareness and promote earlier diagnoses and prompt intervention in this increasingly rare otologic infection., Data Sources: Pubmed/Medline, CINAHL (EBSCOhost), and Web of Science articles in all languages were searched., Study Selection: Inclusion criteria were that the article was either a case report, case series, or retrospective review with individual case data available. Non-English articles were excluded if they lacked an English language abstract and if that abstract lacked information on baseline demographics, clinical presentation, and management., Data Extraction: Included studies were evaluated using fulltext review and demographics, etiology, microbiology, antibiotic usage, and surgical variables were collected., Data Synthesis: Data were qualitatively synthesized, with means and averages obtained for all continuous variables., Conclusions: Bezold's abscess remains a rare otologic infection, but they are relatively commonly associated with serious neurologic and systemic complications. Delay in diagnosis was a frequent commonality and diagnostic vigilance is tantamount in avoiding this sequelae. Aggressive surgical extirpation and long-term antibiotic treatment is recommended., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

The incidence of acoustic neuromas in the United States is 1.09 per 100,000 with 23,739 newly diagnosed cases in the years 2004 to 2010. Because the recent literature has supported that frailty can serve as a more accurate predictor of patient outcomes when evaluated with age, and is an important variable to consider in the course of patient treatment. The objective of this study was to compare the outcomes of frail patients who had undergone surgery for acoustic neuroma with their non-frail counterparts.The authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for acoustic neuroma between 2016 and 2017 by using the Nationwide Readmission Database. A total of 396 frail patients and 402 non-frail patients were identified through the database of undergoing surgery for acoustic neuroma. Frail patients had statistically higher rates of readmission (p < 0.01), post-operative infection (p < 0.01), facial paralysis (p < 0.01), urinary tract infection (p < 0.01), hydrocephalus (p < 0.01), and dysphagia (p < 0.01). These post-op morbidities likely led to the increased length of stay (p < 0.01), non-routine discharge (p < 0.01), and all payer cost seen in frail patients (p < 0.01). However, no significant difference was found between frail and non-frail patients with regards to CSF leak, post hemorrhagic anemia, myocardial infarction, and mortality. Patient frailty status is a significant predictor of poor outcomes in the postoperative sequelae of acoustic neuroma surgery. Further, models including patient frailty plus age outperformed those using age alone for prediction of several postoperative complications., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed., Study Design: A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given., Setting: Patients with nonabsorbable nasal packing placed., Methods: Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model., Results: The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective., Conclusions: Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence., Level of Evidence: 3a.

We present a case of an 80-year-old male who developed skull base osteomyelitis after nasopharyngeal cyst removal. A review of the literature regarding complications after nasopharyngeal cyst removal was performed. We describe the difficulty of diagnosing an osteomyelitis infection and the best approach to recognizing osteomyelitis before complications worsen.

Purpose: Enzymatic polysorbate (PS) degradation and resulting free fatty acid (FFA) particles are detrimental to biopharmaceutical drug product (DP) stability. Different types and grades of polysorbate have varying propensity to form FFA particles. This work evaluates the homogenous all-oleate (AO) PS80 alongside heterogeneous PS20 and PS80 grades in terms its propensity to form FFA particles and other important attributes like interfacial protection and oxidation susceptibility., Methods: FFA particle formation rates were compared by degrading PS using non-immobilized hydrolases and fast degrading DP formulations. Interfacial protection of monoclonal antibodies (mAbs) was assessed by agitation studies in saline using non-degraded and degraded PS. Several antioxidants were assessed for their ability to mitigate AO PS80 oxidation and subsequent mAb oxidation by a 40°C placebo stability study and a 2, 2'-Azobis (2-amidinopropane) dihydrochloride stress model, respectively., Results: Visible and subvisible particles were significantly delayed in AO PS80 formulations compared with heterogeneous PS20 and PS80 formulations. Non-degraded AO PS80 was less protective of mAbs against the air-water interface compared with heterogeneous PS20. Interfacial protection by AO PS80 improved upon degradation owing to high surface activity of FFAs. Diethylenetriaminepentaacetic acid (DTPA) completely mitigated AO PS80 oxidation unlike L-methionine and N-Acetyl-DL-Tryptophan. However, DTPA did not mitigate radical mediated mAb oxidation., Conclusion: AO PS80 is a promising alternative to reduce FFA particle formation compared with other PS types and grades. However, limitations observed here---such as lower protection against interfacial stresses and higher propensity for oxidation---need to be considered in assessing the risk/benefit ratio in using AO PS80.

Background: Real-time polymerase chain reaction using nasopharyngeal swabs is currently the most widely used diagnostic test for SARS-CoV-2 detection. However, false negatives and the sensitivity of this mode of testing have posed challenges in the accurate estimation of the prevalence of SARS-CoV-2 infection rates., Objective: The purpose of this study was to evaluate whether technical and, therefore, correctable errors were being made with regard to nasopharyngeal swab procedures., Methods: We searched a web-based video database (YouTube) for videos demonstrating SARS-CoV-2 nasopharyngeal swab tests, posted from January 1 to May 15, 2020. Videos were rated by 3 blinded rhinologists for accuracy of swab angle and depth. The overall score for swab angle and swab depth for each nasopharyngeal swab demonstration video was determined based on the majority score with agreement between at least 2 of the 3 reviewers. We then comparatively evaluated video data collected from YouTube videos demonstrating the correct nasopharyngeal swab technique with data from videos demonstrating an incorrect nasopharyngeal swab technique. Multiple linear regression analysis with statistical significance set at P=.05 was performed to determine video data variables associated with the correct nasopharyngeal swab technique., Results: In all, 126 videos met the study inclusion and exclusion criteria. Of these, 52.3% (66/126) of all videos demonstrated the correct swab angle, and 46% (58/126) of the videos demonstrated an appropriate swab depth. Moreover, 45.2% (57/126) of the videos demonstrated both correct nasopharyngeal swab angle and appropriate depth, whereas 46.8% (59/126) of the videos demonstrated both incorrect nasopharyngeal swab angle and inappropriate depth. Videos with correct nasopharyngeal swab technique were associated with the swab operators identifying themselves as a medical professional or as an Ear, Nose, Throat-related medical professional. We also found an association between correct nasopharyngeal swab techniques and recency of video publication date (relative to May 15, 2020)., Conclusions: Our findings show that over half of the videos documenting the nasopharyngeal swab test showed an incorrect technique, which could elevate false-negative test rates. Therefore, greater attention needs to be provided toward educating frontline health care workers who routinely perform nasopharyngeal swab procedures., (©Kyohei Itamura, Arthur Wu, Elisa Illing, Jonathan Ting, Thomas Higgins. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 14.01.2021.)

Objective: Cadaveric simulations have shown endonasal drilling and cautery generate aerosols, which is a significant concern for otolaryngologists during the COVID-19 era. This study quantifies aerosol generation during routine rhinologic surgeries and in-office procedures in live patients., Methods: Aerosols ranging from 0.30 to 10.0 μm were measured in real-time using an optical particle sizer during surgeries and in-office procedures. Various mask conditions were tested during rigid nasal endoscopy (RNE) and postoperative debridement (POD)., Results: Higher aerosol concentrations (AC) ranging from 2.69 to 10.0 μm were measured during RNE ( n = 9) with no mask vs two mask conditions ( P = .002 and P = .017). Mean AC (0.30-10.0 μm) were significantly higher during POD (n = 9) for no mask vs a mask covering the patient's mouth condition (mean difference = 0.16 ± 0.03 particles/cm 3 , 95% CI 0.10-0.22, P  < .001). There were no discernible spikes in aerosol levels during endoscopic septoplasty (n = 3). Aerosol spikes were measured in two of three functional endoscopic sinus surgeries (FESS) with microdebrider. Using suction mitigation, there were no discernible spikes during powered drilling in two anterior skull base surgeries (ASBS)., Conclusion: Use of a surgical mask over the patient's mouth during in-office procedures or a mask with a slit for an endoscope during RNE significantly diminished aerosol generation. However, whether this reduction in aerosol generation is sufficient to prevent transmission of communicable diseases via aerosols was beyond the scope of this study. There were several spikes in aerosols during FESS and ASBS, though none were associated with endonasal drilling with the use of suction mitigation., Level of Evidence: 4., Competing Interests: The authors have no conflict of interest to disclose., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC. on behalf of The Triological Society.)

With the largest viral loads in both symptomatic and asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) present in the oral and nasal cavities, agents that act on these two areas have the potential for large therapeutic and prophylactic benefit. A literature review was conducted to elucidate the possible agents useful in treatment of SARS-CoV-2. These agents were evaluated for their current applications, adverse reactions, their current state of study, and any future considerations in their management of coronavirus disease 2019 (COVID-2019). Our review has found that, while there are many promising agents with proven efficacy in their in-vitro efficacy against SARS-CoV-2, more clinical trials and in-vivo studies, as well as safety trials, must be conducted before these agents can be effectively implemented., (© 2021. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Background: The coronavirus disease (COVID-19) is the latest pandemic of the digital age. With the internet harvesting large amounts of data from the general population in real time, public databases such as Google Trends (GT) and the Baidu Index (BI) can be an expedient tool to assist public health efforts., Objective: The aim of this study is to apply digital epidemiology to the current COVID-19 pandemic to determine the utility of providing adjunctive epidemiologic information on outbreaks of this disease and evaluate this methodology in the case of future pandemics., Methods: An epidemiologic time series analysis of online search trends relating to the COVID-19 pandemic was performed from January 9, 2020, to April 6, 2020. BI was used to obtain online search data for China, while GT was used for worldwide data, the countries of Italy and Spain, and the US states of New York and Washington. These data were compared to real-world confirmed cases and deaths of COVID-19. Chronologic patterns were assessed in relation to disease patterns, significant events, and media reports., Results: Worldwide search terms for shortness of breath, anosmia, dysgeusia and ageusia, headache, chest pain, and sneezing had strong correlations (r>0.60, P<.001) to both new daily confirmed cases and deaths from COVID-19. GT COVID-19 (search term) and GT coronavirus (virus) searches predated real-world confirmed cases by 12 days (r=0.85, SD 0.10 and r=0.76, SD 0.09, respectively, P<.001). Searches for symptoms of diarrhea, fever, shortness of breath, cough, nasal obstruction, and rhinorrhea all had a negative lag greater than 1 week compared to new daily cases, while searches for anosmia and dysgeusia peaked worldwide and in China with positive lags of 5 days and 6 weeks, respectively, corresponding with widespread media coverage of these symptoms in COVID-19., Conclusions: This study demonstrates the utility of digital epidemiology in providing helpful surveillance data of disease outbreaks like COVID-19. Although certain online search trends for this disease were influenced by media coverage, many search terms reflected clinical manifestations of the disease and showed strong correlations with real-world cases and deaths., (©Thomas S Higgins, Arthur W Wu, Dhruv Sharma, Elisa A Illing, Kolin Rubel, Jonathan Y Ting, Snot Force Alliance. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 21.05.2020.)

Background: Endoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences., Methods: An anonymous 32-item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi-square, and Fisher exact tests., Results: Seventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full-time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P  = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice ( P  = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high-flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs ( P  < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2-8 weeks and positive airway pressure use for 2-6 weeks. Most respondents started saline irrigations 0-2 weeks postoperatively., Conclusions: Based on responses from fellowship- and non-fellowship-trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS., Level of Evidence: 5.

Background & Aims: Patients undergoing gastrointestinal operations are at risk of malnutrition which may increase the chance of adverse surgical outcomes. This prospective study aimed at correlating nutritional status of patients having gastrointestinal operations with their short-term surgical outcomes captured by a territory-wide Surgical Outcomes Monitoring and Improvement Program., Methods: The preoperative malnutrition risk of Chinese adult patients undergoing elective/emergency ultra-major/major gastrointestinal operations in two surgical departments over a 12-month period were assessed by Chinese version of Malnutrition Universal Screening Tool. Their perioperative risk factors and clinical outcomes, including length of hospital stay, mortality and morbidity, were retrieved from the above mentioned program. Correlation of malnutrition risk with clinical outcomes was assessed by logistic regression analysis after controlling for known confounders., Results: 943 patients (58% male; mean age 65.9 ± 14.8 years) underwent gastrointestinal operations (40.3% emergency operation; 52.7% ultra-major procedures; 66.9% bowel resections) had analyzable data. 15.8% and 17.1% of patients were at medium and high risk of malnutrition, respectively. Malnutrition risk score according to the screening tool was an independent predictor of length of hospital stay, 30-day mortality, 60-day mortality and minor medical complications. Similar correlations were found for various sub-scores of malnutrition risk. Weight loss sub-score was predictive of 30-day mortality, 60-day mortality and minor medical complications. Body mass index was predictive of mortality (30- and 60- day) whereas the acute disease sub-score was predictive of length of hospital stay., Conclusions: Preoperative malnutrition was an important predictor of poor clinical outcomes in patients undergoing gastrointestinal operations in Hong Kong., (Copyright © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer, with 600,000 new cases every year worldwide. Although chemotherapeutics exist, five-year survival is only 50%. New strategies to overcome drug resistance are required to improve HNSCC treatment. Curcumin-difluorinated (CDF), a synthetic analog of curcumin, was packaged in liposomes and used to evaluate growth inhibition of cisplatin resistant HNSCC cell lines CCL-23R and UM-SCC-1R generated from the parental cell lines CCL-23 and UM-SCC-1 respectively. Growth inhibition in vitro and expression levels of the CD44 (cancer stem cell marker), cytokines, and growth factors were investigated after liposomal CDF treatment. The in vivo growth inhibitory effect of liposomal CDF was evaluated in the nude mice xenograft tumor model of UM-SCC-1R and the inhibition of CD44 was measured. Treatment of the resistant cell lines in vitro with liposomal CDF resulted in a statistically significant growth inhibition (p < 0.05). The nude mice xenograft study showed a statistically significant tumor growth inhibition of UM-SCC-1R cells and a reduction in the expression of CD44 (p < 0.05), indicating an inhibitory effect of liposomal CDF on CSCs. Our results demonstrate that delivery of CDF through liposomes may be an effective method for the treatment of cisplatin resistant HNSCC.

Medical treatment of chronic rhinitis is successful in a majority of patients, but there is a still large population of patients who fail medical therapy. Surgical treatment for patients with severe persistent allergic rhinitis is not a new solution, but recent advancements in technology and surgical technique have made surgery safer and more effective. There is no gold standard of treatment in patients with refractory rhinitis, and surgeons may select a variety of procedures and techniques based on a patient's anatomy, severity of disease, and comorbidities. Unfortunately, there are currently few large prospective, randomized controlled trials evaluating surgical treatments, and no study to date has compared immunotherapy to surgical intervention. Therefore, there is no hard and fast rule as to when to pursue surgical intervention after initial medical therapy has failed.

Objective: To establish the feasibility of studying the impact of integrative East-West medicine (IEWM) on sinonasal symptoms and quality of life (QOL) for patients with chronic rhinosinusitis (CRS)., Design: Prospective, nonrandomized trial., Setting: Academic hospital and ambulatory clinic., Patients: Patients with recalcitrant CRS offered treatment with IEWM in addition to standard medical treatment., Methods: Prior to study enrollment, study participants were given the Sino-Nasal Outcome Test (SNOT-20) and the 36-Item Short Form (SF-36) questionnaires., Interventions: Patients underwent 8 weeks of weekly acupuncture and counseling on dietary modification, lifestyle changes, and acupressure., Main Outcome Measures: Patients completed posttreatment SNOT-20 and SF-36 surveys, which were compared for changes in sinonasal symptoms and QOL measures., Results: Eleven patients completed the protocol. No adverse events were observed. There were trends toward improvement in most elements of the SNOT-20, whereas "need to blow nose" (P = .002), "runny nose" (P = .04), "reduced ability to concentrate" (P = .005), and "feeling frustrated, restless, or irritable" (P = .046) were statistically significant. In the SF-36, role physical (P = .01), vitality (P = .04), and social functioning (P = .008) were significantly improved., Conclusions: Preliminary data suggest that an integrated approach of traditional Western medicine with IEWM is safe and may improve symptoms and QOL for patients with recalcitrant CRS. Future randomized controlled trials are needed to validate the effects of IEWM and clarify its role in the treatment of CRS.

Background: recently, there has been a debate regarding total thyroidectomy vs hemithyroidectomy for papillary thyroid microcarcinoma (PTMC)., Objective: to determine whether there were significant differences in the treatment of PTMC depending on a physician's experience, age, training, and location., Methods: a 10-question survey was distributed to otolaryngologists, general surgeons, and endocrine surgeons. It included 4 clinical scenarios, 2 questions querying clinical reasoning, and 4 demographic questions (training, surgical volume, location, and age). The demographic variables were used to analyze responses to the 4 clinical scenarios with bivariate and multivariate statistics., Results: a total of 438 responders completed the survey. Given a single subcentimeter PTMC, 70.3% of surgeons recommended no further surgery after a hemithyroidectomy, yet 29.7% believed that completion thyroidectomy was necessary. Otolaryngologists chose total thyroidectomy more frequently, as did surgeons from the South and West. Given PTMC with lymphatic invasion, 392 (89.5%) responders recommended completion thyroidectomy, with otolaryngologists again more inclined toward completion surgery. Given multifocal PTMC, 85.4% chose completion thyroidectomy, with surgeons in the South and West recommending total thyroidectomy more frequently compared with those in the Northeast. Improved survival, surgeon preference, and need for thyroid suppression were rated relatively insignificant. Ease of patient follow-up and multifocality of disease were judged very significant. Influence from national guidelines and current literature was rated as only somewhat or minimally significant., Conclusions: in this survey, most surgeons seemed to follow national guidelines regarding the surgical treatment of PTMC. However, significant differences in the treatment and perception of PTMC exist based on surgical training and location.

Pediatric chronic rhinosinusitis, a common problem, has been found to have a severe impact on the quality of life. As in the case with adult chronic rhinosinusitis, pediatric chronic rhinosinusitis is difficult to treat, with resultant frequent recurrences and failures. Controversy has existed in the treatment of chronic rhinosinusitis in children, mirroring the controversy over the exact etiology of this disorder. Chronic rhinosinusitis may indeed be a group of diseases with similar presenting features. This article attempts to delineate treatment options that are both safe and effective for pediatric chronic rhinosinusitis.

Polyarteritis nodosa is a systemic necrotising vasculitis that affects the small- and medium-sized arteries. Multifocal aneurysmal formation in the renal, hepatic, and mesenteric vasculature is a hallmark of this condition, and spontaneous aneurysmal rupture may occur, resulting in life-threatening haemorrhage. We describe a 42-year-old man who initially presented with fever of unknown origin. A diagnosis could not be reached at that time despite extensive investigations. The fever subsided spontaneously after 8 weeks, and the patient remained well for 6 years until he was admitted again for evaluation of fever. During his hospital stay, he developed a spontaneous massive intra-hepatic haemorrhage resulting in hepatic rupture and a haemoperitoneum. The bleeding was controlled at emergency laparotomy. An abdominal angiography demonstrated multiple microaneurysms in the hepatic and mesenteric arterial vasculature. The clinical findings suggested polyarteritis nodosa, and the source of bleeding was probably a ruptured intra-hepatic artery aneurysm.